Strategic measures for the control of surging antimicrobial resistance in Hong Kong and mainland of China

Cheng, Vincent CC; Wong, Sally CY; Ho, Pak-Leung; Yuen, Kwok-Yung

Control of antibiotic resistance in China VCC Cheng et al 9 environmental disinfection with focus on frequently touched areas should be enforced. 114, 115 MRSA-positive cases are best nursed in isolation rooms. 111 However, with limited number of isolation facilities in many hospitals, innovative measures should be implemented to prioritize the utilization of isolation rooms. Our study previously found higher transmissibility of MRSA with certain spa types, 116 and the use of broad-spectrum antibiotics could increase bacterial loads leading to an increased risk of environmental contamination by patients with asymptomatic colonization of MRSA; 95 therefore single room isolation is reserved for MRSA patients with the aforementioned characteristics. For other MRSA-positive patients, implementation of 2% chlorhexidine gluconate daily bathing, in addition to the hand hygiene campaign and contact precautions in open cubicles, could limit nosocomial transmission of MRSA in our highly endemic setting. 117 Decolonization of MRSA may reduce the burden of MRSA. The use of a 5-day regimen of nasal mupirocin ointment, chlorhexidine mouth rinse and whole-body wash with didecyldimonium chloride gave an eradication rate of 65% (33/51) after a median follow-up of 13 months, compared with a spontaneous clearance rate of 22% (6/27) in the non-decolonized group. 118 Recently, a study involving 74 adult intensive care units suggested that universal decolonization may be more effective than targeted decolonization or screening and isolation in reducing the rates of clinical MRSA isolates and bloodstream infections due to any pathogen. 119 In contrast to MRSA decolonization, VRE decolonization is more controversial. Bacitracin-containing regimens given orally or via a gastrostomy tube for 10 to 29 days have been reported. [120] [121] [122] [123] [124] Although the overall observed rate of VRE clearance was found to be 43%-100% in patients treated with these bacitracin-containing regimens, 120, 122, 124 long-term follow-up showed that persistent decolonization of VRE was observed in 33%-53% of patients at three weeks post-treatment. 121, 123 The use of Lactobacillus rhamnosus GG or Lactobacillus rhamnosus Lcr35 had been attempted to decolonize VRE patients, but the results were variable. [125] [126] [127] The failure of these regimens is likely to be related to the lack of an effective decolonization regimen, and prolonged asymptomatic carriage of VRE in the gastrointestinal tract will perpetuate the endemicity of VRE in healthcare settings. We have recently introduced a novel regimen for VRE decolonization. Sustained decolonization of gastrointestinal carriage of VRE has been achieved by a combination of environmental disinfection, patient isolation, bowel preparation to wash-out the fecal bacterial population using polyethylene glycol, a five-day course of oral absorbable linezolid and non-absorbable daptomycin to suppress any remaining VRE, and subsequent oral Lactobacillus rhamnosus GG to reinstate colonization resistance. 128 This strategy should be further studied in settings of low VRE endemicity with limited isolation facilities. Residential care homes for the elderly are considered potential reservoirs for MDROs in many parts of the world. 129, 130 In Hong Kong, residents from residential care homes for the elderly account for an estimate of 7% of acute hospital admissions. In a recent prevalence study, the rate of asymptomatic nasal MRSA carriage was